For patients with hypertension, the basic BP-control target is
<140/<90 mm Hg, but the target is
<130/<80 mm Hg for patients with diabetes or renal disease.

Thiazide diuretics are recommended as
initial therapy for uncomplicated hypertension, either alone or in combination
with other agents.

Most hypertensive patients will require 2 or more medications to achieve
BP goals.
When initial BP is more than 20/10 mm Hg above goal, clinicians should consider
initiating therapy with 2 agents, usually including a diuretic.

The authors emphasize the importance of the physician-patient relationship
and patient motivation in fostering treatment adherence.

Lifestyle Modification

Weight reduction if overweight

Reduce sodium intake to ? 100 mmol/day: 2.4 g sodium, 6 g salt

Increase aerobic exercise: 3045 min/day

Limit alcohol intake to ? 1 oz/day

Maintain adequate intake of potassium: 90 mmol/day

Eat a diet rich in fruits, vegetables, and low-fat dairy products but reduced
in saturated and total fat

Hypertensive Urgency is defined as a clinical setting
of severe hypertension with minimal
or no symptoms, where severe elevation of BP are not causing
immediate end-organ damage but should be effectively lowered within 24 hours
to reduce potential risk to the patient.

Symptoms as:

Headache, Visual Changes, Papilledema

Chest Pain (MI), Pain to Back (Dissection)

Abdominal Pain - abdominal aneurysmal dissection

Flank Pain - renal disease

Mental Status Changes - stroke, leukoencephalopathy

ACP PIER 2006

Approach to Hypertensive
Emergency/Crisis

Distinguish between a hypertensive emergency and a pseudocrisis in patients
with markedly elevated BP.

Do not use parenteral or sublingual drugs to treat markedly elevated BP
(>180/110 mm Hg to 220/120 mm Hg) in the absence of symptoms or progressive
target organ damage.

Use the following treatment approaches:

Administer one or more rapid-onset oral antihypertensive
drugs (e.g., furosemide, propranolol, captopril, clonidine, or
nicardipine); once BP is less than 180/110 mm Hg, administer a longer-acting
formulation and recheck the BP within 48 hours.

Administer a longer-acting oral formulation from the start and recheck BP
in 48 hours.

Consider hospitalizing a patient with hypertensive emergency for parenteral
antihypertensive medication when BP is sufficiently
elevated to cause target organ damage (imminent) or is judged to have caused
or played a role in present (ongoing) target organ damage.
Specifically, considering hospitalizing hypertensive patients
with:

Coronary disease and crescendo angina

Heart failure with increasing shortness of breath

Abrupt worsening of renal function

Headache, blurred vision, and increasing disorientation or confusion

Past hypertensive end-organ damage

Recent vascular surgery

Organ transplantation

Known aortic aneurysm or a tearing sensation between the scapulae

A child with previously normal BP may have a hypertensive emergency at a
BP not considered particularly worrisome in an adult. Use clinical judgment
to determine need for hospitalization.

A pregnant woman with previously normal or low BP may have a hypertensive
emergency at a BP not considered particularly worrisome in a nonpregnant
adult. Use clinical judgment to determine need for hospitalization.

Measure the BP more than once or twice and carefully track it before declaring
an emergency. The duration of this tracking will vary according
to clinical presentation.

Monitor the BP in a setting where intravenous antihypertensive drugs can
be given rapidly.

Quick Exam in Severe Hypertension Yes or No

Are pressures equal in the arms?

Are femoral pulses present?

Is grade III or IV retinopathy present?

Is the patient oriented?

Are pupils equally dilated?

Is the neck stiff?

Are rales or an S3 present?

Are abdominal bruits present?

Are there overt neurologic deficits?

Quick History in Severe Hypertension Yes or No

Was antihypertensive therapy recently interrupted?

Are neurologic symptoms present?

Were they sudden in onset: i.e., over minutes to hours?

Did they occur gradually over days?

Is severe headache present?

Have visual disturbances occurred?

Has nausea or vomiting occurred?

Is severe dyspnea present?

Is the patient pregnant?

Does the patient have worsening angina?

Is the patient post- vascular surgery (including CABG)?

Has the patient taken sympathomimetics or cocaine?

Is the patient taking a MAOI antidepressant ?

Situations In Which Severe Hypertension Constitutes
a Crisis

Heart/Vascular

Left ventricular failure

MI

Unstable angina

After vascular surgery or CABG

Aortic dissection

Brain

Hypertensive encephalopathy

Subarachnoid hemorrhage

Intracranial hemorrhage

Thrombotic stroke with severe hypertension

Miscellaneous

Severe catecholamine excess:

Pheochromocytoma

Clonidine withdrawal

Tyramine/MAOI interaction

LSD/cocaine/phencyclidine/phenylpropanolamine use

Eclampsia in pregnancy

Antihypertensive Agents That Are Useful in Hypertensive Crises to guide
treatment of patients with:

Markedly elevated BP and high intracranial pressure

Progressive azotemia

Coronary ischemia

Acute left ventricular failure

Eclampsia

Suspected aortic dissection

Catecholamine excess

Suspected aortic dissection, and in the perioperative setting

EMERGENCY TREATMENT
OF HYPERTENSIVE CRISIS
Antihypertensive Agents That Are Useful in Hypertensive Crises

Esmololol (Breviblock®) Mainly for acute aortic dissection, perioperatively, acute coronary
ischemia
May be used with caution in acute MI with depressed LV to modulate heart
rate
Very short half life (2-4 minutes) non-selective ß-blockade
Dose is 250-500µg/kg/min for 1 minute, then 50-100µg/kg for 4
minutes
Sequence may be repeated, and continuous drip may be maintained
Onset of action is 1-2 minutes; 10-20 minute duration
Very close monitoring is required, and fluid load is large with this agent

Distinguish between a hypertensive emergency and a pseudocrisis in patients
with markedly elevated BP.

Do not use parenteral or sublingual drugs to treat markedly elevated BP
(>180/110 mm Hg to 220/120 mm Hg) in the absence of symptoms or progressive
target organ damage.

Use the following treatment approaches:

Administer one or more rapid-onset oral antihypertensive
drugs (e.g., furosemide, propranolol, captopril, clonidine, or
nicardipine); once BP is less than 180/110 mm Hg, administer a longer-acting
formulation and recheck the BP within 48 hours.

Administer a longer-acting oral formulation from the start and recheck BP
in 48 hours.

In less than hypertensive crises, but in
hypertension urgency:
one or more rapid-onset oral antihypertensive drugs, as: